Justia Insurance Law Opinion Summaries

Plaintiff, the personal representative of the Estate of Gaye S. Glaser, appealed the district court's affirmance of the Medicare Appeals Council's (MAC) ruling that Kaiser was not required to pay for Glaser's liver surgery. Plaintiff contended that by refusing to cover the procedure, Kaiser failed to comply with 42 C.F.R. 422.112(a)(3), which required Medicare Advantage plans to make their services available, accessible, and adequate, and 42 C.F.R. 422.112(a)(9) and 422.113(b)(iii), which required the plans to cover "urgently needed services." The court held that substantial evidence supported the MAC's decision and affirmed the judgment.

Appellant Margerita Cervantes allegedly contracted hepatitis C as a result of treatment she received at the Endoscopy Center of Southern Nevada (ECSN). Appellant obtained treatment at ECSN as part of the health care benefits she received through her culinary union. The union operated a self-funded ERISA health care plan and retained Respondents, Health Plan of Nevada and other health and life insurance entities, as its agents to assist in establishing a network of the plan's chosen medical provider. Appellant filed a lawsuit alleging that Respondents were responsible for her injuries because they failed to ensure the quality of care provided by ECSN and referred her to a blatantly unsafe medical provider. The district court concluded that Cervantes' claims were preempted by ERISA section 514(a). The Supreme Court affirmed, holding that state law claims of negligence and negligence per se against a managed care organization contracted by an ERISA plan to facilitate the development of the ERISA plan's network of health care providers were precluded by ERISA section 514.

Respondent brought this action against appellant to compel payment of no-fault benefits in the amount of its bill, plus statutory interest and attorney's fees, alleging that it had provided timely notice and proof of claim under 11 NYCRR 65-1.1, which required an insured person's assignee to submit written proof of claim no later than 45 days after the date health care services were rendered. At issue was whether a health care services provider, as assignee of a person injured in a motor vehicle accident, could recover no-fault benefits by timely submitting the required proof of claim after the 30-day period for providing written notice of the accident had expired. The court held that the submission of the proof of claim within 45 days of the date health care services were rendered could not serve as timely written notice of accident after the 30-day period for providing such written notice had expired.

Plaintiff, the executor of a decedent's estate, settled medical malpractice claims against several medical care providers for the decedent's wrongful death. Plaintiff then initiated this action against Defendant, the Indiana Patient's Compensation Fund, for damages that exceeded the $250,000 future value of her settlement with the medical providers pursuant to the Indiana Medical Malpractice Act. The trial court awarded Plaintiff the full amount. Defendant appealed, challenging the trial court's ruling that damages under the Adult Wrongful Death Statute (AWDS) included expenses of administration, contingent attorney fees, and loss of services. The court of appeals affirmed the trial court. The Supreme Court affirmed, holding that such damages may be sought under the AWDS.

Defendant in this case issued health care insurance policies to provide coverage for medical services and entered into contracts with practitioners of the healing arts to provide those services. Plaintiffs, three individual podiatrists and the Connecticut Podiatric Medical Association, brought an action against Defendant, alleging that Defendant's practice of reimbursing individual podiatrists at a lower rate than medical doctors for the same service constituted unfair discrimination in violation of the Connecticut Unfair Insurance Practices Act (CUIPA) and the Connecticut Unfair Trade Practices Act (CUTPA). The trial court granted summary judgment in favor of Defendant. The Supreme Court affirmed, holding that CUIPA, by prohibiting unfair discrimination, bars the denial of reimbursement on the basis of the particular license held by a practitioner of the healing arts, but does not preclude setting different reimbursement rates on the basis of the particular license held by a practitioner of the healing arts.

Dane Shattuck died from injuries after being hit by an automobile. Dane received medical care at Hospital for his injuries. Dane was enrolled in a children's health insurance program (CHIP), administered by the department of public health and human services (DPHHS). Hospital submitted the bill for Dane's care to Blue Cross and Blue Shield (BCBS), which served as third-party administrator of the CHIP program for DPHHS. Hospital then asserted a lien for the full bill amount against recoveries Gail Shattuck, as personal representative of Dane's estate, may obtain against third parties. Shattuck sued Hospital, BCBS, DPHHS, and the State, asserting that Defendants unlawfully acted to avoid application of "made whole" rules and that Hospital could not foreclose the lien because Shattuck had not been made whole. The district court granted partial summary judgment to Shattuck. The Supreme Court reversed in part and affirmed in part, holding (1) the district court erred by determining that CHIP constitutes insurance and was governed by the made whole doctrine, and (2) the district court did not err by determining that BCBS was not an insurer in its role here and, therefore, was not subject to the made whole statute. Remanded.

The State of Arizona appealed the district court's order granting a preliminary injunction to prevent a state law from taking effect that would have terminated eligibility for healthcare benefits of state employees' same-sex partners. The district court found that plaintiffs demonstrated a likelihood of success on the merits because they showed that the law adversely affected a classification of employees on the basis of sexual orientation and did not further any of the state's claimed justifiable interests. The district court also found that plaintiffs had established a likelihood of irreparable harm in the event coverage for partners ceased. The court held that the district court's findings and conclusions were supported by the record and affirmed the judgment.

In attempting to enroll his infant daughter, a covered employee failed to complete parts of the form indicating whether the child resided with employee, was dependent upon employee for more than 50 percent support and maintenance, and whether the child qualified to be claimed as a tax exemption on employee's federal tax return. The plan made several inquiries before sending a notice that coverage was denied. The employee did not appeal. The plan sued under the Employee Retirement Income Security Act , 29 U.S.C. 1001, to recover $472,357.84 paid to the medical college and $1,199,538.58 paid to the hospital on behalf of the child. The district court dismissed. The Seventh Circuit affirmed dismissal of the ERISA claim. The plan reserves the right to recover against "covered persons" if it has paid them or any other party on their behalf. Neither the treating entities nor the child are covered persons. Because the plan is not implicated, state law claims were not preempted; the court reversed dismissal of those claims. Plaintiffs' position was not unreasonable; the district court abused its discretion in awarding attorney fees.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

Plaintiff, 37-years-old, suffered from anorexia nervosa for more than twenty years. At issue was whether defendant was required to pay for her care at a residential treatment facility, either under the terms of her insurance plan or under California's Mental Health Parity Act (Parity Act), Cal. Health & Safety Code 1374.72. The court held that plaintiff's plan did not itself require that defendant pay for residential care for her anorexia nervosa. The court held, however, that the Parity Act provided that defendant "shall provide coverage for the diagnosis and medically necessary treatment" of "severe mental illnesses," including anorexia nervosa. Therefore, defendant was foreclosed from asserting that plaintiff's residential care was not medically necessary. Accordingly, the court held that defendant was obligated under the Parity Act to pay for plaintiff's residential care, subject to the same financial terms and conditions it imposed on coverage for physical illnesses.